PINE SHADOW RETREAT

The nursing staff is the most important part of what determines the quality of care and comfort of a resident in a nursing home. Government regulations set expectations on time spent with each resident based on the services being provided. The breakdown below lists the nursing types (RN, LPN, LVN, CNA) and a comparison of the reported and expected hours per resident per day.

Medicare determines quality of care ratings for nursing facilities by surveying several "quality measures", which are broken down into long-term and short-term stay residents, as well as if the action is preventive or if there is a deficiency in the quality of care. State averages for Texas are also provided for comparison purposes. Note: Figures below are averaged over the past nine months.

Long-Term Stay Preventive Actions

Long-Term Stay Deficiencies

All Medicare and/or Medicaid certified nursing home must undergo health inspections on average once a year, but may be more frequent if the facility is peforming poorly. These inspections cover most aspects of life in a nursing home, and are broken down into deficiencies types, which including: Pharmacy Service, Administration, Resident Rights, Nutrition and Dietary, Resident Assessment, Environmental, and Mistreatment. Below are the list of deficiencies found by inspectors in the past few years along with the degree of harm and how many residents may have been affected. Note: The most recent health survey was on 02/24/2011.

Administration

Be Administered in a Way That Leads to the Highest Possible Level of Well Being for Each Resident. Inspection Date: 02/10/2010 Correction Date: 03/26/2010
Make Sure That Nurse Aides Show They Have the Skills to Be Able to Care for Residents. Inspection Date: 02/10/2010 Correction Date: 03/26/2010
Make Sure That Nurse Aides Show They Have the Skills to Be Able to Care for Residents. Inspection Date: 02/24/2011 Correction Date: 04/25/2011

Environmental

Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents. Inspection Date: 01/28/2009 Correction Date: 03/12/2009
Make Sure That the Nursing Home Area is Safe, Easy to Use, Clean and Comfortable. Inspection Date: 01/28/2009 Correction Date: 03/12/2009
Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents. Inspection Date: 02/10/2010 Correction Date: 03/26/2010
Have a Program to Keep Infection from Spreading. Inspection Date: 02/10/2010 Correction Date: 03/26/2010
Make Sure There is a Program to Prevent/Deal with Mice, Insects, or Other Pests. Inspection Date: 02/10/2010 Correction Date: 03/26/2010
Have a Program to Keep Infection from Spreading. Inspection Date: 02/24/2011 Correction Date: 04/25/2011

Mistreatment

Keep Each Resident Free from Physical Restraints, Unless Needed for Medical Treatment. Inspection Date: 02/10/2010 Correction Date: 03/26/2010

Nutrition and Dietary

Store, Cook, and Give out Food in a Safe and Clean Way. Inspection Date: 02/10/2010 Correction Date: 03/26/2010

Pharmacy Service

Keep the Rate of Medication Errors (Wrong Drug, Wrong Dose, Wrong Time) to Less Than 5%. Inspection Date: 02/10/2010 Correction Date: 03/26/2010
Have Drugs and Other Similar Products Available, Which Are Needed Every Day and in Emergencies, and Give Them out Properly. Inspection Date: 02/10/2010 Correction Date: 03/26/2010
Properly Mark Drugs and Other Similar Products. Inspection Date: 02/10/2010 Correction Date: 03/26/2010
Have Drugs and Other Similar Products Available, Which Are Needed Every Day and in Emergencies, and Give Them out Properly. Inspection Date: 02/24/2011 Correction Date: 04/25/2011
Properly Mark Drugs and Other Similar Products. Inspection Date: 02/24/2011 Correction Date: 04/25/2011

Quality Care

Give Each Resident Care and Services to Get or Keep the Highest Quality of Life Possible. Inspection Date: 01/28/2009 Correction Date: 03/12/2009
Make Sure That Each Resident Who Enters the Nursing Home Without a Catheter is Not Given a Catheter, Unless It is Necessary. Inspection Date: 01/28/2009 Correction Date: 03/12/2009
Give Proper Treatment to Residents with Feeding Tubes to Prevent Problems (Such As Aspiration Pneumonia, Diarrhea, Vomiting, Dehydration, Metabolic Abnormalities, Nasal-Pharyngeal Ulcers) and Help Restore Eating Skills, if Possible. Inspection Date: 01/28/2009 Correction Date: 03/12/2009
Properly Care for Residents Needing Special Services, Including: Injections, Colostomy, Ureostomy, Ileostomy, Tracheostomy Care, Tracheal Suctioning, Respiratory Care, Foot Care, and Prostheses. Inspection Date: 01/28/2009 Correction Date: 03/12/2009
Give Residents Proper Treatment to Prevent New Bed (Pressure) Sores or Heal Existing Bed Sores. Inspection Date: 02/10/2010 Correction Date: 03/26/2010
Make Sure That Residents with Reduced Range of Motion Get Proper Treatment and Services to Increase Range of Motion. Inspection Date: 02/10/2010 Correction Date: 03/26/2010
Make Sure That Each Resident's Nutritional Needs Were Met. Inspection Date: 02/10/2010 Correction Date: 03/26/2010
Give or Get Special Rehabilitation if in the Patient's Plan of Care. Inspection Date: 02/10/2010 Correction Date: 03/26/2010
Give or Get Dental Care for Each Resident. Inspection Date: 02/10/2010 Correction Date: 03/26/2010
Give Residents Proper Treatment to Prevent New Bed (Pressure) Sores or Heal Existing Bed Sores. Inspection Date: 02/24/2011 Correction Date: 04/25/2011

Resident Assessment

Develop a Complete Care Plan That Meets All of a Resident's Needs, with Timetables and Actions That Can Be Measured. Inspection Date: 01/28/2009 Correction Date: 03/12/2009
Make a Complete Assessment That Covers All Questions for Areas That Are Listed in Official Regulations. Inspection Date: 02/10/2010 Correction Date: 03/26/2010
Do a New Assessment After Any Major Change in a Resident's Physical or Mental Health. Inspection Date: 02/10/2010 Correction Date: 03/26/2010

Resident Rights

Provide Services to Meet the Needs and Preferences of Each Resident. Inspection Date: 02/10/2010 Correction Date: 03/26/2010
Allow Residents to Easily See the Results of the Nursing Home's Most Recent Survey. Inspection Date: 02/24/2011 Correction Date: 04/25/2011

The table below lists incident reports by the nursing staff or administration for Pine Shadow Retreat, as well as complaints by residents or their family in the previous three years.

Nutrition and Dietary

Make Sure That the Attending Doctor Orders Special Diets. Complaint Filed: 08/04/2010 Correction Date: 09/16/2010

Resident Rights

Provide Care in a Way That Keeps or Builds Each Resident's Dignity and Self Respect. Complaint Filed: 08/04/2010 Correction Date: 09/16/2010

Nursing homes certified by Medicare and/or Medicaid are required to have fire safety inspections to meet Life Safety Code (LSC) standards. Below is a list of deficiencies that Pine Shadow Retreat had in recent fire safety inspections. This information can be used to see if all standards were met, the degree of harm, the number of residents affected, and the date when deficiencies were corrected. Note: The most recent fire safety survey was on 02/23/2011.

Automatic Sprinkler Systems

An Approved Automatic Sprinkler System Connected to the Fire Alarm System. Inspection Date: 01/27/2009 Correction Date: 03/23/2009
Automatic Sprinkler Systems That Have Been Maintained in Working Order. Inspection Date: 01/27/2009 Correction Date: 03/23/2009
Portable Fire Extinguishers. Inspection Date: 01/27/2009 Correction Date: 03/23/2009
An Approved Automatic Sprinkler System Connected to the Fire Alarm System. Inspection Date: 02/12/2010 Correction Date: 03/26/2010
Properly Working Alarms on Sprinkler Valves. Inspection Date: 02/23/2011 Correction Date: 04/23/2011
Automatic Sprinkler Systems That Have Been Maintained in Working Order. Inspection Date: 02/23/2011 Correction Date: 04/23/2011
Portable Fire Extinguishers. Inspection Date: 02/23/2011 Correction Date: 04/23/2011

Building Construction

Approved Construction Type or Materials. Inspection Date: 02/12/2010 Correction Date: 03/26/2010

Building Service Equipment

Heating and Ventilation Systems That Have Been Properly Installed According to the Manufacturer's Instructions. Inspection Date: 01/27/2009 Correction Date: 03/23/2009
An Externally Vented Heating System. Inspection Date: 01/27/2009 Correction Date: 03/23/2009
Heating and Ventilation Systems That Have Been Properly Installed According to the Manufacturer's Instructions. Inspection Date: 02/12/2010 Correction Date: 01/01/1900
An Externally Vented Heating System. Inspection Date: 02/12/2010 Correction Date: 03/26/2010
Properly Protected Cooking Facilities. Inspection Date: 02/23/2011 Correction Date: 04/23/2011

Corridor Walls and Doors

Corridor and Hallway Doors That Block Smoke. Inspection Date: 01/27/2009 Correction Date: 03/23/2009
Signs That State That Exit Doors Are to Be Kept Closed. Inspection Date: 01/27/2009 Correction Date: 03/23/2009
Corridor and Hallway Doors That Block Smoke. Inspection Date: 02/23/2011 Correction Date: 04/23/2011

Electrical

Weekly Inspections and Monthly Testing of Generators. Inspection Date: 01/27/2009 Correction Date: 03/23/2009
Properly Installed Electrical Wiring and Equipment. Inspection Date: 01/27/2009 Correction Date: 03/23/2009
Properly Installed Electrical Wiring and Equipment. Inspection Date: 02/12/2010 Correction Date: 03/26/2010
Weekly Inspections and Monthly Testing of Generators. Inspection Date: 02/23/2011 Correction Date: 04/23/2011
Properly Installed Electrical Wiring and Equipment. Inspection Date: 02/23/2011 Correction Date: 04/23/2011

Exits and Egress

Exits That Are Accessible at All Times. Inspection Date: 01/27/2009 Correction Date: 03/23/2009

Fire Alarm Systems

A Fire Alarm System That Can Be Heard Throughout the Facility. Inspection Date: 01/27/2009 Correction Date: 03/04/2009
An Approved Installation, Maintenance and Testing Program for Fire Alarm Systems. Inspection Date: 01/27/2009 Correction Date: 03/23/2009
Properly Maintained Smoke Detectors. Inspection Date: 01/27/2009 Correction Date: 03/23/2009
An Approved Installation, Maintenance and Testing Program for Fire Alarm Systems. Inspection Date: 02/23/2011 Correction Date: 04/23/2011

Furnishings and Decorations

Exits That Are Free from Obstructions and Can Be Used at All Times. Inspection Date: 01/27/2009 Correction Date: 03/23/2009
Properly Sized and Located Linen or Trash Receptacles. Inspection Date: 01/27/2009 Correction Date: 03/23/2009
Restrictions on the Use of Flammable Curtains. Inspection Date: 02/23/2011 Correction Date: 04/23/2011

Hazardous Area

Construction That Can Resist Fire for One Hour or an Approved Fire Extinguishing System. Inspection Date: 01/27/2009 Correction Date: 03/23/2009
Construction That Can Resist Fire for One Hour or an Approved Fire Extinguishing System. Inspection Date: 02/12/2010 Correction Date: 03/26/2010
Construction That Can Resist Fire for One Hour or an Approved Fire Extinguishing System. Inspection Date: 02/23/2011 Correction Date: 04/23/2011

Illumination and Emergency Power

Proper Backup Exit Lighting. Inspection Date: 01/27/2009 Correction Date: 03/23/2009
Emergency Lighting That Can Last at Least 1 1/2 Hours. Inspection Date: 01/27/2009 Correction Date: 03/23/2009
Proper Backup Exit Lighting. Inspection Date: 02/23/2011 Correction Date: 04/23/2011

Medical Gases and Anesthetizing Areas

Proper Medical Gas Storage and Administration Areas. Inspection Date: 02/23/2011 Correction Date: 04/23/2011

Smoke Compartmentation and Control

Walls or Barriers That Prevent Smoke from Passing Through and Would Resist Fire for at Least One Hour. Inspection Date: 02/12/2010 Correction Date: 03/26/2010
Walls or Barriers That Prevent Smoke from Passing Through and Would Resist Fire for at Least One Hour. Inspection Date: 02/23/2011 Correction Date: 04/23/2011
Proper Construction of Ducts Through Walls Designed to Prevent Smoke Passage. Inspection Date: 02/23/2011 Correction Date: 04/23/2011

Smoking Regulations

Posted "No-Smoking" Signs in Areas Where Smoking is Not Permitted or Did Not Provide Ashtrays Where Smoking Was Allowed. Inspection Date: 02/12/2010 Correction Date: 03/26/2010